Organization
GRANT DISICK MD PA
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. GRANT I DISICK MD (PRESIDENT)
(561) 487-5506
Entity
Organization
Contact information
Practice address
9970 CENTRAL PARK BLVD N, SUITE 207, BOCA RATON, FL 33428-2231
(561) 487-5506
(561) 487-9261
Mailing address
9970 CENTRAL PARK BLVD N, SUITE 207, BOCA RATON, FL 33428-2231
(561) 487-5506
(561) 487-9261
Taxonomy
Speciality
Code
Description
License number
State
208800000X
Urology Physician
Primary
ME101748
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
11763982
CAQH
FL
01
—
ME101748
LICENSE
FL
Enumeration date
10/08/2010
Last updated
01/11/2011
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